Pharmacy coverage changes and 2026 formulary updates
October 2026| Harvard Pilgrim Health Care Commercial| Tufts Health Direct| Tufts Health RITogether| Tufts Health Together
The chart below identifies updates for Pharmacy Medical Necessity Guidelines. For additional details and to access the guidelines referenced below, please visit the Pharmacy Medical Necessity Guidelines page on our Point32Health provider website.
| Drug status changes | |||
| Drug | Plan | Eff. Date | Policy and Additional Information |
| Acid Suppressive Therapy | Harvard Pilgrim Commercial, Tufts Health Direct | 1/1/2027 | Oral solution and oral suspension formulations of histamine H2-receptor antagonists that are covered by the plan will be subject to prior authorization. Updated the title of Medical Necessity Guideline from Proton Pump Inhibitors to Acid Suppressive Therapy and revised the document to additionally apply to H2-receptor antagonists. See “2027 drug status and formulary updates” section below for further details. (Consistent with Maine regulations, a redlined version of this policy is also posted temporarily.) |
| Cladribine tablets | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together | 1/1/2027 | Cladribine tablets will be added to the specialty pharmacy program provided by Optum Specialty. |
Azelastine Olopatadine 0.1% and 0.2% Epinastine Bepotastine Alocril (nedocromil) Alomide (lodoxamide) | Tufts Health RITogether | 12/1/26 | Anti-Allergy Medications, Ophthalmic Our Pharmacy Medical Necessity Guideline (PMNG) titled Anti-Allergy Medications, Ophthalmic will be retired. Epinastine, bepotastine, Alocril, and Alomide will be removed from our preferred drug list and coverage will be reviewed according to our PMNG titled Pharmacy Products Without Specific Criteria. Azelastine, olopatadine 0.1% and 0.2% will be covered without prior authorization. |
| Contrave (naltrexone/bupropion) | Tufts Health RITogether | 12/1/26 | Anti-Obesity Medications Initial authorization for Contrave will require additional trial and failure of therapy with phentermine/topiramate extended-release (generic Qsymia). |
| Ferriprox (deferiprone) | Tufts Health RITogether | 12/1/26 | Iron Chelating Agents Initial authorization for deferiprone oral tablet, Ferriprox Twice-A-Day oral tablet, and Ferriprox oral solution will require trial and failure with deferasirox. For Ferriprox oral solution, clinical inappropriateness of therapy with deferiprone oral tablet formulation administered three times per day will be also be required. |
2027 drug status and formulary updates
Please refer to this document to review drug status and formulary changes for Harvard Pilgrim Commercial and Tufts Health Direct for the 2027 plan year, including:
- Drugs moving to non-formulary status
- Drugs moving to a higher tier
- Drugs with prior authorization added
2027 drug status and formulary updates for Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, and Tufts Health One Care will be announced in the November issue of Insights and Updates for Providers.